MORTGAGE APPLICATION

Referral: ___________________________
Applicant Information
Full Name Present Address Previous Address: (if less than 3 years at current) S.I.N. Postal Code Date of Birth Dependants Rent/Own Marital Status No. Of Years No. Of Years

$
Rent/Own

$
Home Phone: Bus Phone: Current Employer Previous Employer: (if less than 3 years at current) 1 2 Home Fax: Bus Fax: Years Years Gross Annual Income Gross Annual Income Cellular: Email: Occupation Occupation

Other Income: Source

Smoker? ____ Yes ____ No

Years

Income
First Time Buyer? _____ Yes ____ No

Occupation

Co-Applicant Information
Full Name Address S.I.N. Postal Code Date of Birth Yrs Marital Status

Home Phone: Business Phone:

Current Employer Previous Employer: (if less than 3 years at current)

Home Fax: Bus Fax:

Years Years Gross Annual Income Gross Annual Income

Cellular: Email: Occupation Occupation

1 2 Other Income
Smoker? ____ Yes ____ No

Years

Gross Annual Income

First Time Buyer? _____ Yes ____ No

Occupation

Assets
Bank: Bank: RRSP: Stocks/Bonds/GIC: Automobile: Automobile: Other Assets: Other Assets: Other Assets: Household Goods: Location: Location: Type: Type: Balance: $ Balance: $ Value: $ Value: $ Value: $ Value: $ Value: $ Value: $ Value: $ Value: $

Liabilities
Bank Loan/LOC Bank Loan/LOC Bank Loan/LOC Credit Card Credit Card Credit Card Credit Card Other Debt: Other Debt: Type: Type: Type: Type: Balance: $ Balance: $ Balance: $ Balance: $ Balance: $ Balance: $ Balance: $ Balance: $ Balance: $
Property Value: $ First: Monthly Payments: $ Rental Income: $ Mortgage Balance: $ Property Value: $ First: Monthly Payments: $ Rental Income: $ Mortgage Balance: $ Property Value: $ First: Monthly Payments: $ Rental Income: $ Mortgage Balance: $ Second: Second: Second:

Payment: $ Payment: $ Payment: $ Payment: $ Payment: $ Payment: $ Payment: $

Current Mortgages/Properties Owned:

Address: Existing Mortgage Bank/Lender: Mortgage Rate: Address: Existing Mortgage Bank/Lender: Mortgage Rate: Address: Existing Mortgage Bank/Lender: Mortgage Rate: % % %

DECLARATION If I have included information in this application in respect of any other person, including a co-applicant, I hereby confirm that such other person(s) has fully authorized me to release their personal information to you and to my Dominion Lending Centres - City Wide Mortgage Services Specialist and that such other person(s) consent to all of the terms set-out herein. The word "Information" means personal information about me and any other person(s) identified in this application, obtained from this application or other sources. I am hereby expressly consenting to the submission of my application and the disclosure of Information to third parties, such as lenders and insurers, for the purpose of arranging and/or renewing mortgage(s). I understand that this will allow lenders to submit commitments for my review. I/we further acknowledge and agree that each potential mortgage lender, mortgage insurer or service provider to whom you provide the mortgage application and/or my/our personal information is permitted to receive such application and information and maintain records relating to me/us, including my/our Social Insurance Number(SIN) if I/we provide it, and collect personal information from me/us, you and from third persons, including credit bureau, credit reporting and collection agencies, financial institutions, my/our past and present employers, creditors and tenants, my/our spouse or any other person who has information about me/us for the purpose of recording, evaluating and responding to my/our application for mortgage financing or related activities and I /we specifically consent to the release and disclosure of personal information by such persons to and among you and each potential mortgage lender, mortgage insurer or other service provider. I hereby consent to and agree that my Mortgage Broker or Agent may use the Information in order to identify me, protect me from fraud and error, understand my needs and eligibility for products and/or services, recommend particular products and services to meet my needs, provide ongoing services, and comply with legal and regulatory requirements. I consent to and agree that my Mortgage Broker or Agent may use the Information for the above-noted purposes and may obtain Information about me from others, including consumer reporting agencies, credit bureaus, financial institutions, and real estate appraisers and may confirm the accuracy of the Information by contacting such third parties. I further consent to and agree that each lender considering my application may obtain Information about me (and all co-applicants) from others, including consumer reporting agencies and other such third parties. I hereby consent to and agree that my Mortgage Broker or Agent may retain the Information after the last mortgage application made on my behalf, or the end of the term of the mortgage, whichever is later and that my Mortgage Broker or Agent may retain and use my personal information for the purposes listed above after the last mortgage application made on my behalf.

Signature: Signature:
Verbal Consent - By Broker

Date: Date:

Date:

Notes:
.